Training on Basic Epidemiology & Surveillance

Learning Objectives
• Determine when health agencies need to
investigate and report health events
• Understand the roles and functions of ESR point
persons
• Know the steps in an outbreak investigation
• Define the terms cluster, outbreak, epidemic
• Identify purpose of linelisting
• Identify and interpret an epidemic curve

Training on Basic Epidemiology & Surveillance

 Who investigate outbreak?

• Local health department

• Regional DOH

• National DOH

Training on Basic Epidemiology & Surveillance

 Why investigate an outbreak?
• Identify the source, control and eliminate
• Develop strategies to prevent future outbreaks
• Evaluate existing prevention strategies
• Describe new diseases and learn more about
known diseases

• Address public concern

Training on Basic Epidemiology & Surveillance
 Why investigate an outbreak?
• To provide agreed upon or mandated services
• To get more information about interaction
among the human host, the agent, and the
environment

• To strengthen surveillance at the local level

• To provide training opportunities

Training on Basic Epidemiology & Surveillance

 Steps of an Outbreak Investigation
1. Prepare for field work

Training on Basic Epidemiology & Surveillance

 Step 1. Preparing for Field Work

2 Broad Categories

•Scientific and Investigative Issues

•Management and operational issues

Training on Basic Epidemiology & Surveillance

 Step 1. Preparing for Field Work
Scientific and Investigative Issues
• study the disease
• study previous field investigations
• ensure proper laboratory material and knowledge on
collection, storage, transport techniques
• consider PPE (personal protective equipment)
• plan of action (clear objectives, accomplishment,
priorities, define “success” in this investigation

Training on Basic Epidemiology & Surveillance

 Step 1. Preparing for Field Work
Management and operational issues

good field investigator = good manager = good

collaborator

• The team composition and their roles & responsibilities

• Prepare communication plan
• Prepare needed operational and logistical resources

Training on Basic Epidemiology & Surveillance

 Steps of an Outbreak Investigation
1. Prepare for field work
2. Establish the existence of an outbreak

Training on Basic Epidemiology & Surveillance

 Step 2. Establish the existence of an
outbreak
Epidemic : the occurrence of more cases of disease than
expected in a given area or population over a period of
time.

Outbreak: epidemic limited to localized increase in the

incidence of disease.

Cluster: aggregation of cases in a given area over time

without regard to whether number is more than
expected.
Training on Basic Epidemiology & Surveillance
 Step 2. Establish the existence of an
outbreak
Excess may not necessarily indicate an outbreak . . .

• reporting procedures change

• case definition change
• local or national awareness increase
• diagnostic procedures improvement
• consistency of a reporting unit is better
• misdiagnosis or laboratory error
• population size sudden changes

Training on Basic Epidemiology & Surveillance

 Steps of an Outbreak Investigation
1. Prepare for field work
2. Establish the existence of an outbreak
3. Verify the diagnosis

Training on Basic Epidemiology & Surveillance

 Step 3. Verify the Diagnosis

Why is it important?

• to properly identify the disease for more specific

control measures
• to rule out laboratory error as basis for increase in
cases

Training on Basic Epidemiology & Surveillance

 Step 3. Verify the Diagnosis

How to verify diagnosis:

• review clinical and laboratory findings for consistency

• visit patients with the disease
• summarize clinical features frequency distributions

Training on Basic Epidemiology & Surveillance

 Steps of an Outbreak Investigation
1. Prepare for field work
2. Establish the existence of an outbreak
3. Verify the diagnosis
4. Construct a working case definition

Training on Basic Epidemiology & Surveillance

 Step 4. Construct a working case definition

Case definition:
A standard set of criteria for deciding whether an individual
should be classified as having the health condition of
interest.
• Must include time, place and person criteria.
• Must not include the exposure or risk factor to
evaluate.
• Create categories of a case definition (possible or
suspect, probable and confirmed)

Training on Basic Epidemiology & Surveillance

Example:
A suspect case is a previously well individual who
attended the wedding on May 19, 2015 of Mr. and Mrs.
BNB in Municipality X and manifested at least two of
the following signs and symptoms; abdominal pain,
loose bowel movement, vomiting, headache and fever
from 19 – 21 May 2015.

Training on Basic Epidemiology & Surveillance

Example:

A confirmed case is a suspect case positive for

Salmonella hvittingfoss and Salmonella potsdam.

Training on Basic Epidemiology & Surveillance

 Steps of an Outbreak Investigation
1. Prepare for field work
2. Establish the existence of an outbreak
3. Verify the diagnosis
4. Construct a working case definition
5. Find cases systematically and record information

Training on Basic Epidemiology & Surveillance

 Step 5. Find cases systematically and
record information
Investigators may conduct:
a. Stimulated or enhanced passive surveillance
- letter
b. Conduct active surveillance
- telephone call
- visiting of health facilities
- house to house visit

Training on Basic Epidemiology & Surveillance

 Step 5. Find cases systematically and
record information

• Recording information by

a. Self made data collection form

b. Generic / standardized case report form

Training on Basic Epidemiology & Surveillance

 Step 5. Find cases systematically and
record information
Data collection form should include the ff:

• Identifying information
• Demographic information
• Clinical Information
• Risk Factor Information
• Reporter Information
Training on Basic Epidemiology & Surveillance
 Steps of an Outbreak Investigation

1. Prepare for field work

2. Establish the existence of an outbreak
3. Verify the diagnosis
4. Construct a working case definition
5. Find cases systematically & record information
6. Perform descriptive epidemiology

Training on Basic Epidemiology & Surveillance

 Step 7. Develop hypothesis
Testable Hypothesis may…
• address the source of the agent
• mode (and vehicle or vector) of transmission
• exposures that caused the disease
•when the epidemiology does not fit the natural
pattern, think unnatural, i.e., intentional.

Training on Basic Epidemiology & Surveillance

 Step 8. Evaluate hypotheses
epidemiologically
Combination of…
• environmental evidence
• laboratory science
• epidemiology
 establishing facts
 analytic epidemiology

Training on Basic Epidemiology & Surveillance

 Step 9. Reconsider, refine and
re-evaluate hypothesis
• when analytic study is unrevealing rethink your
hypothesis
• consider convening a meeting of the case-patients
for more common links, exposures, modes of
transmission

Training on Basic Epidemiology & Surveillance

 Step 10. Compare and reconcile with
laboratory and environmental studies

• laboratory findings to confirm epidemiology

results
• complement to the inescapable conclusion

Training on Basic Epidemiology & Surveillance

 Step 11. Implement control and
preventive measures
• GOAL of all outbreak investigation…
>
>
• in practice, P&C should be done, ASAP!
• confidentiality concerns
• measures directed throughout chain of
transmission
Training on Basic Epidemiology & Surveillance
 Step 12. Initiate or maintain
surveillance

• once Prevention & Control is

implemented… monitor!
• is it working?
• did it spread to other areas?

Training on Basic Epidemiology & Surveillance

 Step 13. Communicate Findings

• summarize findings
• oral briefing
• written report

Training on Basic Epidemiology & Surveillance

 Step 13. Communicate Findings

• summarize findings
• oral briefing
• written report

Training on Basic Epidemiology & Surveillance

 Steps of an Outbreak Investigation
1. Prepare for field work
2. Establish the existence of an outbreak
3. Verify the diagnosis
4. Construct a working case definition
5. Find cases systematically and record information
6. Perform descriptive epidemiology
7. Develop hypothesis
8. Evaluate hypothesis epidemiologically
9. As necessary, reconsider, refine, and re-evaluate hypothesis
10. compare and reconcile with laboratory and environmental
studies
11. Implement control and prevention measures
12. Initiate or maintain surveillance
13. Communicate findings

Training on Basic Epidemiology & Surveillance